 <div class="row">
                    	
                        <div class="col-lg-12 col-md-12 col-sm-12 register-account">
                        	
                            <div class="carousel-heading no-margin">
                                <h4>Register</h4>
                            </div>
                            
                            <div class="page-content">
                            	<div class="row">
                                	
                                    <div class="col-lg-12 col-md-12 col-sm-12">
                                    	<p><strong>Shopper information</strong></p>
                                    </div>
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>E-Mail*</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Username*</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Displayed name*</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Password</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Confirm Password</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>I agree to the terms of service</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="checkbox" id="i-agree-to-terms"><label for="i-agree-to-terms"></label>
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                
                                    <div class="col-lg-12 col-md-12 col-sm-12">
                                    	<p><strong>Bill to</strong></p>
                                    </div>
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Company Name</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Title</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<select class="chosen-select">
                                        	<option>Mr</option>
                                            <option>Mrs</option>
                                        </select>
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>First name</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Middle Name</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Last Name</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Address 1</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Address 2</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>ZIP / Postal Code</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>City</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Country</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>State / Province / Region</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Phone</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>Mobile Phone</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                </div>
                                
                                <div class="row">
                                    
                                    <div class="col-lg-4 col-md-4 col-sm-4">
                                    	<p>FAX</p>
                                    </div>
                                    <div class="col-lg-8 col-md-8 col-sm-8">
                                    	<input type="text">
                                    </div>	
                                    
                                    <div class="col-lg-12 col-md-12 col-sm-12">
                                    	<input class="big" type="submit" value="Register">
                                        <input class="big" type="reset" value="Cancel">
                                    </div>
                                    
                                </div>
                            </div>
                            
                    	</div>
                          
                    </div>